Provider Demographics
NPI:1053951608
Name:KELLY, MARISSA ANN (LPC)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 GRACELAND RD
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16105-2344
Mailing Address - Country:US
Mailing Address - Phone:724-657-4960
Mailing Address - Fax:
Practice Address - Street 1:2702 GRACELAND RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105-2344
Practice Address - Country:US
Practice Address - Phone:724-657-4960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-12
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC011203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC011203OtherPROFESSIONAL COUNSELOR